“Gender-based Violence (GBV) and HIV, they are like sister and brother”: barriers and facilitators to GBV screening and referral in public HIV treatment settings in Uganda

Background People living with HIV are vulnerable to gender-based violence (GBV), which can negatively impact HIV treatment outcomes. National guidelines in Uganda recommend GBV screening alongside HIV treatment services. We explored barriers and facilitators to providers implementing GBV screening and referral in public antiretroviral therapy (ART) clinics in Uganda. Methods We conducted qualitative in-depth interviews. Providers were purposively sampled from 12 ART clinics to represent variation in clinical specialty and gender. We used the Theoretical Domains Framework to structure our deductive analysis. Results We conducted 30 in-depth interviews with providers implementing GBV screening and/or referral. Respondents had a median age of 36 (IQR: 30, 43) years and had been offering post-GBV care to clients for a median duration of 5 (4, 7) years. 67% of respondents identified as female and 57% were counselors. Facilitators of GBV screening and referral included providers having access to post-GBV standard operating procedures and screening tools, trainings offered by the Ministry of Health, facility-sponsored continuing medical education units and support from colleagues. Respondents indicated that referrals were uncommon, citing the following barriers: negative expectations regarding the quality and quantity of referral services; lack of financial resources to support clients, facilities, and referral partners throughout the referral process; and sociocultural factors that threatened client willingness to pursue post-GBV support services. Conclusions Findings from this evaluation support the refinement of GBV screening and referral implementation strategies that leverage facilitators and address barriers to better support individuals living with HIV and who may have heightened vulnerability to GBV.


Background
The United Nations defines gender-based violence (GBV) as any act of violence directed towards an individual on the basis of their gender, and which results in physical, sexual or psychological harm [1].While evidence indicates that women are disproportionately affected, men and gender diverse individuals also experience GBV.Intimate partner violence (IPV) is the most common manifestation of GBV and refers to acts or threats of harm that occur between individuals in an intimate relationship [1].The World Health Organization (WHO) reports that 27% of women aged 15-49 experience lifetime, and 13% of women experience past-year physical or sexual IPV [2].National estimates from Uganda eclipse global averages-with 39% of Ugandan married women and men indicating that they had experienced physical, sexual, or emotional violence in the past year [3].Among everpartnered women, the National Survey on Violence in Uganda estimates that 22% report having experienced physical, 28% sexual and 36% emotional violence in the past year [4].IPV exposure has been associated with poor mental and physical health outcomes including increased risk of depression, suicidality, HIV acquisition, and poorer engagement with HIV services [5].
In alignment with the Uganda Domestic Violence Act of 2010 and the President's Emergency Plan for AIDS Relief (PEPFAR) guidance to screen for GBV in HIV treatment and prevention settings, the Uganda Ministry of Health identifies systemic interventions that address GBV as high-priority strategies for reducing the risk of HIV acquisition and supporting retention in care for people living with HIV [6][7][8][9].The Uganda Consolidated Guidelines for the Prevention and Treatment of HIV and AIDS highlight the interconnected nature of GBV and HIV by outlining national recommendations to routinely offer GBV screening and referral to clients in antiretroviral therapy (ART) clinics [6].Given the cooccurring nature of GBV and HIV, ART clinics represent an opportune environment for identifying and supporting IPV-exposed individuals.Providers play a key role in identifying and supporting ART clinic clients who may be disproportionately vulnerable to GBV exposure because of positive HIV serostatus.Although screening in healthcare settings has been found to increase identification of individuals experiencing violence, only an estimated 10% of providers routinely screen for IPV, globally [10][11][12].There is some evidence that provider-level barriers to GBV screening in Ugandan healthcare settings may include GBV stigma; lack of screening knowledge or training; and perceptions that screening is beyond their professional scope [13].However, factors influencing the implementation of GBV screening and referral guidelines alongside HIV services are under-articulated in Uganda and other resource-constrained settings.Thus, we aimed to identify barriers and facilitators to GBV screening and referral by providers in public ART clinics in Uganda.

Study design
We conducted individual, semi-structured in-depth interviews (IDIs) with providers in 12 ART clinics in the Kampala and Wakiso Districts of Uganda-the two most densely populated districts in Uganda's Central Region.Participating ART clinics were in urban or peri-urban settings.Further, all health facilities had a designation of Health Centre III or greater (i.e., serve catchment areas of > 20,000 people and are the lowest level at which GBV screening is offered) and were affiliated with the Partners PrEP Program (PPP; #NCT03586128)-the parent study which was an implementation trial that integrated oral pre-exposure prophylaxis (PrEP) and ART delivery [14].PPP provided the research team with a foundation of rapport with facility administrators and providers as well as understanding of clinic processes.

Recruitment
Our study team engaged facility leadership and solicited their recommendations of providers suitable for study participation.We then approached these providers to describe the study and gauge interest to participate in a one-time interview.Providers were eligible to participate if they were: engaged in GBV screening and/or referral; proficient in English; willing and able to provide informed consent and 18 years of age or older.We purposively recruited providers and sought representation across the spectrum of clinical specialties, (i.e., counselors, medical officers, nurses, outreach, and linkage facilitators) and gender (i.e., male or female).

Data collection and analysis
Authors DT (United States-based female) and AN (Uganda-based female) used a semi-structured interview guide to conduct IDIs in English or Luganda, depending on respondent preference.We used the Theoretical Domains Framework (TDF) [15,16] to guide data collection and analysis.The TDF is an implementation science determinants framework that integrates 33 behavior change theories by characterizing their key factors into 14 domains (e.g., knowledge, skills and social influences) that facilitate the elaboration of cognitive and behavioral influences upon implementation success [15].We selected this framework because we identified it is as being well-suited for evaluating behavioral influences on providers' implementation of GBV screening/referral.The research team collaboratively developed the interview guide, which was informed by the TDF, literature reviews, and prior understanding of provider behaviors.Our interview guide explored 11 out of 14 TDF domains (i.e., the optimism, intentions and goals domains were excluded) deemed most relevant for assessing barriers and facilitators to GBV screening/referral (Table 1).IDIs were audio recorded, translated into English (where applicable), and transcribed.
We used a deductive approach to data organization and analysis which was informed by recommendations for leveraging the TDF for qualitative research [17].We developed our study codebook by incorporating TDF domains as codes, adapting publicly available TDF domain descriptions to our evaluation context and including illustrative examples for codes.We went line-by-line applying domains of the TDF as codes to transcripts (Table 1).When excerpts were relevant to multiple domains, they were cross coded.The coding team consisted of three US-based female researchers (DT, MR and MM), all of whom possess advanced qualitative research methods training.Four transcripts were jointly coded to refine codebook definitions and promote agreement across the team.Remaining transcripts were independently coded using the finalized codebook.Code application was then audited by another team member.Discrepancies were identified, discussed, and collaboratively reconciled.Upon conclusion of transcript coding and auditing, we generated reports for each TDF domain which summarized data and highlighted key barriers and facilitators for each domain.We conducted two analysis workshops with the broader study team during which we reviewed, discussed and collaboratively built consensus regarding the interpretation of salient study findings.We used Dedoose Software (Version 9.0.86) for data management and analysis [18].

Participant characteristics
From August to December 2022, we conducted 30 inperson IDIs with providers in 12 public ART clinics (median interview duration: 56 min, interquartile range (IQR): 45, 68]).Most (67%) respondents were female, median age was 36 years (IQR: 30, 43), and providers had been offering post-GBV care to clients for a median of 5 years (IQR: 4, 7, Table 2).57% of respondents were counselors, 20% medical officers, 13% outreach or linkage facilitators and the remaining 10% were nurses.77%  of respondents had attained a bachelor's degree or higher level of education.

Theoretical domains
Findings are outlined below and organized by the 11 TDF domains explored in this analysis (e.g., knowledge, skills, social/professional role and identity).In some instances, domains were co-occurring, so relevant findings concurrently presented.

Knowledge
Respondents reported a high level of knowledge about GBV.Participants demonstrated dynamic conceptualizations of GBV that were gender-inclusive and included financial control as well as social harms including stigma.
We are looking for mental.We are looking for physical.We are looking for sexual.Any form of GBV… So you find that it is very hard to find [a client] that is not undergoing GBV.We look out for all that and we ask, "If your family members are stigmatizing you…"" -Counselor, 34-year-old, Female.
Respondents expressed knowledge about how GBV exposure might influence HIV-related health outcomes.
We believe that this GBV and HIV, they are like sister and brother.Now, like in Africa… here in Uganda you'll find that actually GBV has caused HIV… You find that somehow these two are getting related, a lot of GBV has caused HIV.GBV is speeding up the transmission of HIV from one partner to the other." -Counselor, 40-year-old, Female.
Participants were aware of screening guidelines and screening tools used to identify and characterize client experiences of GBV.Although participants generally perceived themselves as possessing the necessary knowledge about screening guidelines, they reported some instances in which providers had uncertainty about the appropriate classification of GBV.This may present inconsistencies in GBV categorization across providers and otherwise threaten the utility of GBV screening data.
For example, the person says, "I'm psychologically tortured because I lost a job…" No one is telling her to be poor or always abusing her, but the person just says, "How will I survive?Where can I get money from?"Where is the GBV in this situation?…Who is the perpetrator?Who is hurting her?There is no one, it is just the situation that is hard for that person.Therefore, that is not GBV… But some people may think that is GBV, because the person is psychologically affected.The person can [classify] it as a GBV, but that's not a GBV.Especially new staff, when they have just come and they don't know, sometimes they categorize that as psychological [violence]." -Counselor, 45-year-old, Female.
Although respondents indicated that they possessed knowledge about GBV screening, some highlighted concerns regarding its implementation in health facilities. In

Social/professional role and identity
All respondents perceived screening clients for GBV as part of their professional role, which represents an important facilitator for screening.Only certain types of providers saw GBV referrals as professionally in-scope.
Respondents largely perceived counselors as responsible for connecting clients to referral services.

It is my superiors [counselors] that refer… to police and other rehabilitation centers. I get cases from the community and hand them over to my superiors. " -
Outreach worker, 49-year-old, Male.

Beliefs about capabilities -emotion
The beliefs about capabilities and emotion domains emerged together.Respondents perceived themselves as capable of enacting GBV screening.They cited trainings, mentorship and prior experiences screening clients as important facilitators for enhancing GBV screening capabilities.When respondents perceived themselves as effectively screening clients for GBV, they reported positive emotions within themselves and within their clients.
When you screen properly and then when they air out their problems and take your advice, when that client is happy, it also brings happiness to you.

Beliefs about consequences -emotion
Respondents underscored the facilitating nature of positive expectations regarding outcomes of GBV screening/ Respondents expressed favorable expectations for the ways in which GBV screening/referral influenced providers and facilities.Namely, participants cited that engaging in GBV screening: (1) refined their GBV knowledge and skills via experiential learning, (2) conferred feelings of contentment that they had successfully supported their client, and (3) improved facility responsiveness to key issues of violence affecting clients.

Yes, of course [screening] helps us as a facility in our decision making and planning purposes to know
where we should increase our efforts.If we are having many cases from the catchment area that we are working in, then we see how to intensify the awareness in the area that you are working." -Counselor, 32-year-old, Male.
Participants reported negative expectations for patient outcomes if they failed to offer GBV screening.Respondents indicated that failing to screen and support GBV-exposed clients could threaten progress towards addressing the HIV burden. We

Reinforcement
Respondents indicated that while there were no official incentives for engaging in GBV screening/referral, an important facilitator was the satisfaction providers received when clients offered feedback indicating that they had been supported.Respondents expressed perceptions that engaging in GBV screening/referral was motivating because it aligned with successful execution of their professional role and contributed to individual as well as community wellness.

Memory, attention, and decision processes
Most respondents indicated that they did not have to make decisions about whether to screen clients for GBV because all clients were supposed to be screened.Some respondents indicated that overwhelming client volume was a barrier to screening all clients in the ART clinic.

Environmental context and resources -behavioral regulation
Some respondents identified understaffing and staff transfers as barriers to offering GBV screening to all clients in ART clinics.
Most of the health facilities are understaffed so human resource is a factor.If we had enough human resource, it would be easier to screen almost everyone." -Counselor, 49-year-old, Male.
Participants identified the following material resources as GBV screening facilitators: screening tools, registry for documenting affected clients, and standard operating procedures outlining guidance for managing clients experiencing violence.Respondents identified the following resources as GBV referral facilitators: GBV referral directory and standard operating procedures outlining referral partners and their contact information.
The environmental context and resources and behavioral regulation domains frequently manifested alongside one another.This is reflected in respondents identifying guidelines and screening tools as facilitating resources for systematically guiding them to implement GBV screening/referral.
We screen [clients] using the guidelines.Those are guided steps.We have a… GBV screening tool that finds out if you are having any issues." -Medical officer, 35-year-old, Female.
We have a protocol which guides on the referral and linkage.The protocol is very clear, and it is able to guide you on the processes that you take when referring a client." -Counselor, 36-year-old, Male.
Some respondents indicated that information in referral directories was static and that the contact information and details of services offered by referral partners were sometimes outdated.This represented a barrier to referral.Participants identified the following as facilitators for referral: (1) phone airtime for contacting referral partners and/or following up with clients, and (2) colleagues to share the responsibility of GBV screening.Respondents identified barriers to referral, including: (1) financial burden to clients of pursuing referrals, (2) lack of financial resources at the facility to ensure successful client referrals, and (3) referral partners lacking the necessary financial resources to adequately support clients.
Clients normally say the police ask for money and they don't have the money.Yeah, so they say to win a police case, you really must be loaded.Because those guys will ask for money." -Counselor, 34-year-old, Female.
Finally, respondents identified quality referral partners as a limited resource.Participants cited referral partners' having a narrow scope and mandates regarding the types of clients served as potential barriers to successful referrals.
Platforms where someone can run for help… There are few and some have limitations.There are those who say they only look after children.Those who say, "No, only women, or this age group." They leave out other age groups yet every person in this world goes through GBV and they will need to be helped at certain moment." -Counselor, 29-year-old, Male.

Social influences
Providers identified influences on clients' willingness to undergo GBV screening and referral including awareness of GBV, fear of being judged because they experienced GBV, shame that community members will learn that a family member caused them harm, gender expectations, and clients requiring consent from a violent partner to pursue additional support services.Respondents indicated that these sociocultural norms undermined client willingness to disclose experiences of violence which posed a barrier to GBV screening/referrals.For example, respondents described how male clients might be judged or emasculated for "coming out" as GBV survivors and participants underscored the barrier that this creates for supporting such clients.

Discussion
We aimed to qualitatively assess barriers and facilitators to providers implementing national and multinational guidelines for GBV screening and referral in public ART clinics in two Ugandan districts.Respondents indicated that they routinely implemented GBV screening and referral in ART clinics and that implementation of GBV screening was facilitated by formal and informal training opportunities.Participants cited support from colleagues as a facilitator for GBV screening and referral.Trainings and peer support reinforced theoretical knowledge of best practices to support clients experiencing GBV.These findings are substantiated by existing evidence identifying experiential learning as a facilitator to providers developing the knowledge, confidence, and skills to support clients with a GBV history [19][20][21].While providers generally indicated that they were capable of implementing GBV screening, many identified barriers to the provision of GBV referrals, particularly to police.Despite respondents' perception that GBV referrals were facilitated by their skills, motivation, and a generally enabling resource environment, participants indicated that it was uncommon for them to refer clients.Our findings are well aligned with those from a 2021 evaluation of the integration of GBV screening into HIV counseling and testing services in Tanzania and South Africa [21].This evaluation similarly found that despite a high burden of GBV-exposed clients, only 10% of clients experiencing GBV were ultimately referred.Providers from our study indicated that the rarity of referrals was influenced by sociocultural factors and negative expectations about clients being supported by referral partners.Respondents expressed concern that referrals might result in the client sustaining additional institutional harm with little assurance that they would receive meaningful assistance.Providers highlighted concerns about financial constraints associated with pursing referral services and referral agents stigmatizing clients.Our findings are corroborated by existing evidence identifying these barriers as critical contributing factors to the gulf preventing clients with a GBV history from receiving support services [22][23][24].When referring clients to post-GBV support services, respondents identified institutional failures that conferred ancillary layers of harm upon already vulnerable clients.This highlights the challenge of providers being capable, willing and appropriately resourced to offer referrals but their efforts being nonetheless compromised due to clients' (perhaps, justified) resistance or inability to accept support.Further, perceptions of the institutional harm sustained by clients contributed to providers' negative expectations about referral provision which may have, in turn, posed a barrier to referral by eroding provider willingness to refer and/or exacerbating vicarious trauma.
Respondents identified aspects of the sociocultural context as barriers to GBV screening/referral.Participants highlighted ways in which harmful gender norms operate as tools of systemic sexist oppression by inhibiting client willingness to accept referrals.For example, due to economic reliance upon male partners or family members, respondents indicated that female clients may forego referrals-choosing, instead, to endure environments of ongoing violence out of necessity for their economic survival.This may point to an opportunity for providers to equip female clients experiencing GBV with skills to deescalate violent scenarios.Relatedly, participants theorized that male clients' willingness to be screened or referred was compromised by fears of being stigmatized for the sociocultural narrative violation of being a male with a personal GBV history.Existing evidence highlights ways in which stigmatizing interactions-including fear of such encounters-may encourage individuals undergoing GBV to refuse social support, thereby reducing their likelihood of engaging in help-seeking behaviors [25][26][27].Our findings echo those of Barnett et al. (2016), who identify stigma as a mechanism for social control.Specifically, they indicate that for individuals with a GBV history, individual, interpersonal and systemic participation in stigma processes work to reinforce the existing social order of male dominance [28].Our observations underscore the importance of ensuring that providers have awareness about the ways in which sociocultural influences may influence clients' engagement with GBV screening/referral as well as provider ability to support clients given constraints imposed by the broader social environment.Further, these findings point to the importance of mobilizing a community response that extends beyond the health facility and promotes a restructured sociocultural context that allows for more effectively connecting individuals to supportive services for GBV.
Our study findings should be contextualized by considering its limitations.We sampled respondents from ART clinics located in public health facilities.These findings may not be applicable in other geographies or to different types of providers (e.g., at private facilities, lower-level health facilities, other health specialties) or who otherwise possess a less favorable attitude to GBV screening/ referral.Further, it is possible that our findings are negatively influenced by social desirability bias.Respondents may have been fearful to share their true experiences of GBV screening/referral due to concerns about being reprimanded for suboptimal performance.Such fears may have compelled some respondents to provide misleading accounts of their GBV screening/referral practices and experiences, although respondents did share numerous challenges.To combat issues of response bias, we assured respondents during informed consent procedures that any information provided would be used solely for research purposes and that no identifying information would be shared with their employer.Another limitation to consider is that we did not capture client-level perspectives about the implementation of GBV screening and referral.Deepening our understanding of client perspectives will be critical for optimizing the effectiveness and impact of GBV screening and referral in ART clinics.

Conclusions
There is limited description of factors influencing the implementation of GBV screening and referral guidelines that have been enacted in Uganda with the goal of organizing a health systems response to concurrently address challenges of GBV and HIV.In this qualitative evaluation among providers in ART clinic settings, we identified several barriers and facilitators to offering GBV screening and referral.Given the disproportionate burden of GBV among individuals living with HIV, it is important to implement bespoke strategies for addressing issues of violence within the context of HIV care.It will be advantageous to develop implementation strategies that enable providers to navigate threats that the sociocultural environment poses to GBV screening and referral and address resourcing challenges that inhibit referral network effectiveness.Future research is needed to incorporate client-level perspectives and evaluate dynamic strategies for enhancing the health systems response to GBV by addressing issues of violence in community settings.

Table 2
Participant characteristics